WP0039099 - Laserfiche WebLink

Home Browse Search

WELUPUMP PERMIT � r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N CITY/ZIP �1 1 ( t\L !_l_j [ E D m JOB ADDRESS �. pp �yQ!T CROSS STREET C >, APN �D-1' ZW— PARCEL SIZE "V` LAND USE APPLICATION## �f�J m C/ PHONE OVDq— l`�✓_ OWNER NAME �rr c'c� /1 Jnr/n,�^ In�, S�.��r� �^ /� � jp OWNER ADDRESS /� U) .l�oL Q,Pd CITY/STATE21P StD �(�L�(f RE2Up CONTRACTORon PHHOO�NE� CONTRACTOR ADDRESS I CITY/STATE/ZIP Arr& L/ ch SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE IC-57 'I C-61 1 D-09 11 Other NUMBER 2 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE XDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization 11 Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK New Well I1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells U Soil Boring(s) _ If of borings C Geotechnical #of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair 1i New Pump 11 Pump Replacement U Pump Repair 11 Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other Proposed Well Depth15 D ft Excavation 1'2 in diameter '] Open Bottom Gravel Pack/Gravel Size Np.k7 in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft &ZAa oxk Well Casing Diameter_�&_ in Thickness/Gauge/ASTM Sched -&DQ2 U Steel k-Plastic L, Stainless Steel ❑ Other Grout Seal Depth 30 ft Il Neat Cement(94 Ib bag/5-10 gal water) )sand Cement1(2.3_s=A_sack mix/7 gal water I.1 Bentonite(20%solids) `I Other Grout Placement Method XPumped `J Free Fall F, Other f) Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Y Pump Contractor ❑ Other Concrete Pedestal-Dimensions:Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible[! Turbine I; Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. \MINIMUM 24 HOUR ADVANCE NOTICE RAEQUU1 R INSPECTIONS- PLEASE CALL (209) 953-7697 SIGNED T V DATE. — (n—I7 ,u 41AY O IQ,JIN C F " XUNMEN L T I ITFF,-F-f+l I I I I I I I I I I I I I I I I I I I 1 11 DEPARTMENT USE0 LY s Application Accepted B Date Area �^ Employee ID# Grout Inspection Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection,By Date Constructed Well Depth )OP ft COMMEN S -'� W MPA �l C1199 hl' PE SC Received Check Amount Date Permit/ Invoice# Well ID# Codes Info B s Remitted Service Request# �3oc'�) 3/ 3 �' 11 SFi?0 '71b VVM05 qol?q a sizes' r / EH —,p s D 3-os M �� T c/r `1 t J ��'�� `�5i�= WELL/PUMP PERMIT r.G ��✓��J ,4 v�l� 1l�'lll�1G�J C�Y3ti`T 7i,c� To�rii�G,L C cry